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FOR OFFICE USE: I/ FOR OFFICE USE- <br /> ------------------------------------------------------- <br /> SE: <br /> _ <br /> ------------------ ----------- ----------- - -- '�! 'q44 -�APPLICATIONFOR SANITATION PERMITPermit No.ZT'6-p <br /> (Complete in Triplicate) •.... , <br /> ------------------------------------------------- + <br /> Date Issued--*_._/_4;�-.78' -� <br /> --------------------- -------- - ------------------------ This Permit Expires 1 Year From Date Issued <br /> 157 <br /> Application is ereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: Y <br /> s - -` .� <br /> tDDRESS/LOCATION.-- - - --- I + ts_ �- CENSUS TRACT r <br /> Owner's Name --- -- -- Phone <br /> Address- *94)Q- - --- ------- - ------ ------ -----------City -------Zip----------------- --- - ---- <br /> - - <br /> ;Contractor's Name_____ <br /> - --------------------------License #.,2_2V=539--------Phone- -_ " <br /> Installation will serve: Y ' Residence ❑� Apartment House.❑ Commerci I ❑ Trailer Court ❑ <br /> § Motel ❑ Other--- <br /> �- - t r <br /> Number of living units:------ ---------Number of bedrooms'------___ --Garbage Grinder------_----Lot Size----- /do__-_x -------------------- r <br /> Water Supply: Public System and name------------------------- <br /> ---- _ Private ElQ i <br /> - <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ElClay Loam ❑ _ "S j <br /> Hardpan❑ Adobe [ Fill Material-------------If yes, type-------------_.----------------- <br /> 1 <br /> s(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) ` <br /> NEW INSTALLATION:' (No sep pa a 'pit permitted if public sewer is available within 200 feet) <br /> a <br /> 1 Size---- -__-��- ----Liquid Depth --- <br /> PACKAGE TREATMENT ,[.1 � - .. � �x-�� 1---------------------- --------- -:-- <br /> Capacityj?,A_U_-._-:Type) _ Material_ ---- --No. Compartments---.--.- <br /> . Distance-to nearest: Well. --- ______________ Foundation-.-- -------------- Prop. Line___.--:- <br /> LEACHING LINE [;]. No. of Lines- ----------- --- ------Length of each line..---- --,::-.-.Total Length ------ .--.---:---.---- <br /> . ; 'D' Box------------Type Filter Material-------------------Depth Filter Mater;ial----------------------------------------------------------;----0 <br /> -# Distanceto nearest: Well-:------'--.-------.-Y-.--.Foundation-----------------------------Property Line--.----.----.--.-- <br /> SEEPAGE PIT [ ] Depth----------------Diameter-.------------------Number-------------------------------- Rock Filled Yes ❑ No ❑ <br /> 1 Water Table Depth---------------- -------------------------- Rock Size--------------------- <br /> - Distance to nearest: Well---- -­------------------------ <br /> Foundation Prop, Line <br /> REPAIR/ADDITION (Preva Sanitation-Permit#----------------------------------------------=-------Date.---------------------------------------------1 <br /> SepticTank (Specify Requirements) --------- -------- ------------- ---- --------------------------------------------------------------- ---------- - ------------------------------ -------- <br /> DisposalField (Specify Requirements)---------------------- ---- ------------------------------------------------------------------------------------------------------------------- --- --- <br /> ---------------------------------- <br /> -- <br /> --------------------------------------------------------------------------------------------- ------------------------------------------ ------------------------------------ ---;­------------------------ ---- <br /> (Draw <br /> --------- - - - ------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: e <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to beco sub' ct tomanCompensation. laws of California." <br /> r( <br /> Signed -----=-------- ------ Owner <br /> BY----------------------- - wn -------------=--------------------'-Title- --- -- t--------------------------- --------- <br /> (if other than er) ' <br /> FQ& DEPA T ONLY <br /> APPLICATION ACCEPTED BY------ / _ - �'` - - ---------------------------------------DATE --------- - - ---- '/'------------------------ <br /> DIVISION OF LAND NUMBER----------- --- ---------------- ------------ DATE./ <br /> ADDITIONAL COMMENTS--------------------- ---------- ---- ---------------------- ------------- : <br /> --- --- ---- ; <br /> -------------------------- --- <br /> - <br /> ----------- --------------------------------------- ------ - - - ---- <br /> Final Inspection by:-------- = ----Date ----- ---------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7)76 3M <br />